The findings from the current analysis suggest that there was wide regional variation in heart failure mortality in the United States, with the highest rate in the Southeastern region. This is very similar to the regional variation in stroke mortality that is also the highest in the Southeastern region of the country and often referred to as the “Stroke Belt” of the country. Taken together with the highest heart failure hospitalization in the Southeastern region of the United States,3, 4
the findings of the current study suggest that the Southeastern region may be burdened by a “Heart Failure Belt”.
Although the presence of the Stroke Belt has been long known, little is known about its causes and hypotheses abound. To better understand the regional variations in stroke mortality, the National Institute of Neurological Disorders and Stroke (NINDS) has funded the REasons for Geographic and Racial Differences in Stroke (REGARDS) study.5
Preliminary findings from REGARDS suggest that the incidence of stroke may be higher in the stroke belt region of the country (unpublished data), a finding that was also demonstrated in National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Followup Study (1971–1987),6
this in part explains the higher stroke mortality.7
However, findings from REGARDS indicate that hypertension awareness and treatment in the Stroke Belt may not be substantially different from those in the rest of the country suggesting that the causes of an increased incidence of stroke in Stroke Belt may be complex and may not be fully explained by regional variation in traditional risk factors.8
The role of non-traditional risk factors and whether there is regional variation in stroke case fatality are currently being studied in REGARDS.
To the best of our knowledge, the presence of a possible Heart Failure Belt in the Southeastern United States is largely unknown. Far lesser is known about the potential causes of the excess heart failure mortality in the Southeastern United States. Large prospective national population studies with strong representation from the Southeastern United States are needed to understand the underlying causes of excess heart failure mortality in this region. REGARDS has enrolled 30,239 participants 45 years or older from the 48 contiguous states between January 2003 and October 2007.6
Because over half of the REGARDS participants are from the Southeastern region of the United States and because there is a robust similarity between regional variations in stroke and heart failure mortality, REGARDS provides a unique opportunity to study the causes of excess heart failure mortality in the Southeastern United States .
Several limitations of our study need to be acknowledged. Because sudden cardiac death and death from progressive HF are the two major modes of death in heart failure, misclassification and underestimation of heart failure mortality rate are possible. Also, the analysis is based on mortality due to heart failure as a primary cause and thus underestimates the total burden of death in all heart failure patients. However, these are likely to be random for all regions of the country and may not confound the regional differences observed in our study. In conclusion, findings from the current analysis demonstrate a profound regional disparity in heart failure mortality in the United States and provide evidence for the existence of a Heart Failure Belt, similar to the Stroke Belt, in the Southeastern region of the United States, where heart failure mortality is the highest in the nation.